Syrian and Russian forces targeting hospitals as a strategy of war

Even as Syria’s fragile ceasefire deal was being hammered out, Syrian government forces and their allies intensified their attacks on medical facilities. “Syrian and Russian forces have been deliberately attacking health facilities in flagrant violation of international humanitarian law. But what is truly egregious is that wiping out hospitals appears to have become part of their military strategy,” said Tirana Hassan, Crisis Response Director at Amnesty International.

“The latest string of attacks on health facilities north of Aleppo appears to be part of a pattern of attacks on medics and hospitals, a strategy that has destroyed scores of medical facilities and killed hundreds of doctors and nurses since the start of the conflict.”

The organization has gathered compelling evidence of at least six deliberate attacks on hospitals, medical centres and clinics in the northern part of the Aleppo Countryside governorate in the past 12 weeks. The attacks, which killed at least three civilians including a medical worker, and injured 44 more, continue a pattern of targeting health facilities in various parts of Syria which amounts to war crimes.

Amnesty International researchers spoke to medical workers from the six medical facilities and several humanitarian organizations in Turkey and Syria, who described their struggle to cope with the high number of civilians in need of medical treatment following the recent escalation of airstrikes on the area in February 2016.

Several medical workers from Anadan and Hreitan, two towns north-west of Aleppo, told Amnesty International that the Syrian government’s strategy is to empty an entire town or village of residents by targeting hospitals and infrastructure to facilitate the ground invasion.

A doctor from Anadan said: “Hospitals, water and electricity are always the first to be attacked. Once that happens people no longer have services to survive. This is what happened in Anadan. By mid-February most of the residents had fled the city after the field hospital and medical centre were attacked on 2 February. The field hospital is barely operating and the centre closed. The problem is that not everyone is able to leave the city.  The ones who stayed behind are elderly people who are in desperate need of medical treatment.”

“Hospitals in opposition-controlled areas around Aleppo became a primary target for the Russian and Syrian government forces. This eliminated a vital lifeline for the civilians living in those embattled areas, leaving them no choice but to flee,” said Tirana Hassan.

All of the people interviewed by Amnesty International said that there were no military vehicles, checkpoints, fighters or front lines near the hospitals that were attacked and that the hospitals were exclusively serving their humanitarian function.

Deliberate attacks on civilians not directly participating in hostilities and on civilian objects, including hospitals and other medical facilities, violate international humanitarian law (also known as the laws of war) and amount to war crimes. Under the laws of war, hospitals and medical units enjoy special protection. They only lose their protection from attacks if they are being used outside their humanitarian function to commit “acts harmful to the enemy” such as to store weapons.

Even in the case of such misuse, a warning has to be issued setting a reasonable time limit and an attack can only take place after such a warning has remained unheeded.

“We have repeatedly called on the Syrian and Russian governments to abide by international humanitarian law and have urged Russia to conduct credible, independent investigations into its forces’ attacks on hospitals and other serious violations,” said Tirana Hassan.

“All medical workers and all health facilities should be respected and protected instead of being targeted. The injured and sick people are stranded at the Turkish border or dying inside Syria because hospitals have become the new front line in the offensive on the northern part of the Aleppo Countryside governorate. There is no excuse for a government to prevent people from accessing medical care. There is no excuse for deliberately targeting hospital after hospital.”

Background and testimonies
According to the Syrian Network for Human Rights, a local monitoring group, at least 27 hospitals, including eight in Aleppo governorate, have been targeted by Russian and Syrian government forces since September 2015. The Syrian American Medical Society (SAMS) told Amnesty International that since December 2015 at least 13 hospitals had been targeted in Aleppo by airstrikes and one by a surface-to-surface missile on 15 February. A total of four medical staff workers and 45 civilians were killed in these 14 attacks.

Physicians for Human Rights has reported that, since the conflict began, at least 346 attacks on medical facilities have been carried out by parties to the conflict, with 705 health workers killed. Syrian government forces and their allies have been responsible for the overwhelming majority of these.

Amnesty International’s researchers focussed on six attacks in northern Aleppo between December 2015 and February 2016.

The offensive on the northern part of Aleppo Countryside 
During the last week of January 2016, Syrian government forces supported by Russian airstrikes began a ground offensive in the northern part of the Aleppo Countryside governorate to break the siege imposed by non-state armed groups on the towns of Nubul and Zahraa. This cut off the supply route from both this area and Turkey to Aleppo city. On 1 February, the Syrian government forces and the Syrian Democratic Forces, which include Kurdish, Arab and Assyrian groups, continued their offensive in the same area.

Civilians who fled the northern part of the Aleppo Countryside governorate to the Bab al-Salam border crossing into Turkey told Amnesty International that Russian and Syrian government airstrikes escalated in the first week of February, forcing thousands of people to flee. With no functioning hospitals left in the area, many of those injured in the airstrikes were forced to drive for hours to obtain medical help. Interviews with doctors and medical workers in and around Aleppo indicate that health facilities were among the first buildings targeted in a series of airstrikes at the start of the offensive, which they believe were intended to reduce the capacity of health facilities and prevent the injured from receiving medical treatment.

Tel Rifaat 
Two doctors and an activist from Tel Rifaat who left two days before the People’s Protection Unit (YPG), part of the Syrian Democratic Forces, took control of the town on 15 February told Amnesty International that all three health facilities, including a field hospital, a rehabilitation centre and a kidney dialysis centre were directly targeted by missiles during the week beginning on 8 February, just as the ground offensive on the town began. The attacks injured six members of the medical team and three civilian patients and left the population with no working medical facility.

Doctor “Faraj” (his real name has been withheld for security reasons), who manages the field hospital, rehabilitation and kidney dialysis centre, told Amnesty International: “The Kurds started gaining control of some villages in the northern part of Aleppo Countryside at the beginning of February and they were advancing towards Tel Rifaat. As they approached, Russian and Syrian forces targeted medical facilities. As a result, the civilians injured from the indiscriminate shelling had to be transferred to the Syrian/Turkish border because the hospitals were no longer operational.”

Several weeks before the current offensive, on 19 December 2015 at 2.45pm, a direct airstrike destroyed a centre in Tel Rifaat which provided medical care for children with special needs. According to the centre’s manager, it had been set up in 2014 and received 250 children per month from all over the northern part of Aleppo Countryside.

Maskan village
A doctor from the Independent Doctors Association (IDA) in Turkey told Amnesty International that the field hospital they support in Maskan, a village in the northern part of Aleppo Countryside, had to be evacuated on 1 February because of intensifying airstrikes and an imminent ground invasion of the village. A day after the medical staff and patients evacuated, the IDA received images of the field hospital destroyed by an airstrike.

The Syrian government gained control of the deserted village on 15 February. Amnesty International reviewed the images of the destruction and a video of government forces inside the field hospital claiming that the facility was used by terrorists to treat the war wounded. International humanitarian law protects hospitals and health facilities carrying out their humanitarian function, including providing medical treatment to wounded fighters.

Anadan
Doctors and a medical worker in Anadan told Amnesty International how two airstrikes on 27 January and 2 February by Russian or Syrian warplanes partially destroyed a field hospital and rendered a rehabilitation centre out of service. A physiotherapist at the rehabilitation centre said:

“The airstrikes intensified on 1 February. The next day at 8.30am the centre was targeted by a missile. I was on my way to work when I saw and heard the explosion. When I arrived I saw the driver’s body at the entrance, two patients and five from the medical team severely injured. We had to transfer them outside of Anadan. Now the centre is out of service. We lost a lot of expensive equipment. We provided treatment to whoever is in need and we have been operating since 2014.”

Hreitan
Baghdad Hospital in Hreitan was directly targeted on 25 December 2015 and severely damaged. A doctor and another medical worker at the hospital told Amnesty International that a Russian or Syrian warplane fired missiles directly at the hospital, injuring 10 medical staff and at least 20 civilian patients, and leaving the facility in ruins. Medical worker Ali Hamedo was killed by the strike. The hospital has been unable to function since.

Doctor “Abdullah” (his real name has been withheld for security reasons) from Hreitan said: “Not even underground hospitals are safe. We moved the hospital underground a year ago assuming that it will be protected from the airstrikes. But the missiles were able to penetrate the underground levels. We have spent hundreds of thousands of dollars to equip the hospital and provide treatment to the injured and sick but now Hreitan has no more hospitals.”

A family from Hreitan who fled the attacks on 6 February told Amnesty International that they were the last ones to leave. The father said, “I have lived in Hreitan all my life and I have never seen it deserted. Very few families remained because they can’t leave the city. The airstrikes destroyed the city’s infrastructure including hospitals so there are no more services for us to be able to survive.”

According to the Russian Ministry of Defence, Russian warplanes carried out strikes on “terrorists’ objects” in Aleppo between 4 and 11 February but denied targeting civilians. The Russian authorities continue to deny killing any civilians or damaging any civilian infrastructure in Syria, despite strong evidence indicating many hundreds of such deaths and multiple attacks on civilian buildings.

On 11 February, the Russian Ministry of Defence accused the US-led coalition of being responsible for the attacks on the northern part of Aleppo Countryside, an accusation denied by the USA. According to the US Central Command (CENTCOM), the US-led coalition carried out strikes on the armed group calling itself Islamic State in Mar’a in the northern part of Aleppo Countryside between 1 and 4 February.